Provider Demographics
NPI:1588064208
Name:COOK, MALCOLM (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 INDIAN RIVER BLVD STE B210
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7113
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-252-3245
Practice Address - Street 1:787 37TH ST STE 140
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7305
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-252-3245
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019878363LP0808X
DCRN1012522363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11019878OtherMEDICAL LICENSE
FL120499400Medicaid